Just wanting a little feedback on how you guys feel about the removal of chest tubes on a post-CABG/Valve pt via an RN. I previously worked @ a hospital were on the Tele/Stepdown Unit I and the other RN's removed chest tubes all the time. The requirements were that you had to have successfully completed ACLS, be an RN, completed a basic critical care course, and be witnessed by a trained person in chest tube removal 3X's prior to being able to remove them yourself. I recently reviewed on the states BON website that it is contraindicated for RN's to remove chest tubes. The hospital that I worked for was the only REGIONAL medical facility in the state and us nurses regularly removed chest tubes as we were given both verbal and written orders by the cardiac surgeons to do so. I guess what I would like is a little feedback on this topic b/c looking back if anything would have went wrong I could have been in some serious trouble in a court of law. I would have been found guilty of practicing a skill outside of a nurses scope of practice. How can a large REGIONAL medical facility allow this to happen when it is clearly stated in the BON?
Registered Nurses are licensed by the state. Your state's nursing practice act defines your scope of practice. If you practice outside of your scope of practice then your state's board of nursing can discipline that RN. This is true regardless of whether or not a physician or your hospital "gives permission" to exceed your scope through an order or a policy.
Unfortunately, whether or not a specific procedure is outside the scope of nursing practice may not be entirely clear. Some states offer specific advisories/directives regarding certain procedures. However many do not, essentially pleading that to define all procedures as permissable (or not) would be overly cumbersome for the board and the nurse alike. Typically, they provide a decision tree to aid the nurse in determining whether a procedure is permitted under the act. Usually the decision tree requires that the procedure is not specifically prohibited by the board, that the facility's nurse executive has blessed the procedure, that a policy/procedure exists for its performance, that the individual has had the education/skills checked off to perform the procedure safely etc....... So be aware that even though a procedure may potentially be within the scope of nursing practice, if your facility has no relevent written policy/procedure, you are subject to be found practicing outside of your scope of practice should an adverse event occur.
As mentioned above, the completion of a course in ACLS in and of itself does not bestow immunity from the above facts. But some RNs can and do perform intubation-----not because they have completed ACLS but rather because their employer has a policy permitting same, they have verified/documented the nurse's training and proficiency etc.
My advice: If your facility does not have a policy regarding a procedure....don't perform it until one is formulated/approved. If you have any doubts regarding whether or not a procedure is within the scope of practice ask for a determination from the board; they might provide a straight answer to your inquiry or refer you to a prior determination they have made------or likely as not refer you to one of those damn decision trees.
HUH?....
Can u translate what u posted...I read it a few times each time scratching my head. Do you write for the BON's because reading your post made me feel like I was reading legal descriptions etc. Hmm...maybe there is a reason I became a nurse and not a lawyer...he he.
I will look into reading the nurse practice act to find out more.
Also I hope I did not imply that completing ACLS made me feel like I should be able to intebate, by no means would I try such a high risk procedure until I had a ton of training and a policy stating it was within my scope of practice(which I do not want to).
One time we had a pt. pull one of her chest tubes out and the nurse who was an LVN called the doc and he said to pull the other one, so she pulled it. She was the only one on the floor that had done it before, none of the RN's knew how. From what she told me, LVN's and RN's can remove them here in Texas, I never followed up and looked it up so I don't know.
I work in SICU (in Texas) so we get all of the hearts and lungs post op, and the nurses pull the chest tubes all the time. I have never thought to look at policy, I just see the nurses doing it all the time. (I am still in school, so naturally I don't touch them). Will definitely investigate before I ever personally pull them...
Can u translate what u posted...I read it a few times each time scratching my head. Do you write for the BON's because reading your post made me feel like I was reading legal descriptions etc. Hmm...maybe there is a reason I became a nurse and not a lawyer...he he.
I will look into reading the nurse practice act to find out more.
Also I hope I did not imply that completing ACLS made me feel like I should be able to intebate, by no means would I try such a high risk procedure until I had a ton of training and a policy stating it was within my scope of practice(which I do not want to).
Your state has an organization known as the Nursing Care Quality Assurance Commission; Visit their web site.
There you will find that they list advisory opinions regarding various procedures (conscious sedation, botox injections etc.) Chest tube removal is not among them, therefore you must use the decision tree to determine whether or not you may pull chest tubes; there is also a form with which to request an advisory opinion by the the Commission.
Finally, if it still appears that you may perform the procedure, make sure that your facility permits same as evidenced by a policy and procedure.
can someone provide me please with a link to where I can see my state's (NY) nurse practice act.
I tried searching but no luck so far....
The NY State Education Department has an Office of Professions; The laws governing nursing practice (there are several) can be located under their website's Laws, Rules and Regulations listing.
Your state has an organization known as the Nursing Care Quality Assurance Commission; Visit their web site.
There you will find that they list advisory opinions regarding various procedures (conscious sedation, botox injections etc.) Chest tube removal is not among them, therefore you must use the decision tree to determine whether or not you may pull chest tubes; there is also a form with which to request an advisory opinion by the the Commission.
Finally, if it still appears that you may perform the procedure, make sure that your facility permits same as evidenced by a policy and procedure.
Clear now?
Ok..makes much more sense...I have visited the site before but it seems difficult to navigate and find the info i'm looking for. I appreciate the clarification...:)
Reply by Larry77 raises a (maybe silly) question. Can a hospital policy supercede a BON directive? i.e. BON says you can but hospital, or med staff, says you can't or vice versa- hospital says you can, but BON says no. Which would hold up in court? Probably the more restrictive, but what does everyone think?
Hey there,
I tend to agree w/ you, regarding this topic holding up in court. I feel that, yes we were trained and had to pass a competency, however, in the event that a negative rx would occur would the fact that it was not w/in a nurses scope of practice cause a malpractice case. The answer is YES. That is what worries me. I will investigate into this issue further.
That is what worries me. I will investigate into this issue further.
Larry77, RN
1,158 Posts
HUH?....
Can u translate what u posted...I read it a few times each time scratching my head. Do you write for the BON's because reading your post made me feel like I was reading legal descriptions etc. Hmm...maybe there is a reason I became a nurse and not a lawyer...he he.
I will look into reading the nurse practice act to find out more.
Also I hope I did not imply that completing ACLS made me feel like I should be able to intebate, by no means would I try such a high risk procedure until I had a ton of training and a policy stating it was within my scope of practice(which I do not want to).